Scoring Systems and Outcome Prediction

  • Rui Moreno
  • Isabel Miranda


The rapid development and proliferation of intensive care units (ICUs) in the Western World during the last years created the systematic need for the evaluation of the effectiveness of their procedures and practices. Are those ICUs admitting the right patients at the right time? Are they discharging the right patients at the right time? Are the processes of care assuring, at the individual level, the best possible patient safety and, at a collective level, the best effectiveness of the clinical and nonclinical practices? In other words, are ICUs caring for the right patients at the right time and having the best possible results? So, in this young but dynamic specialty, there still exists little scientific evidence as to what treatments and practices are effective, and especially about the costs and the efficiency of the delivered care.


Intensive Care Unit Admission Sequential Organ Failure Assessment Sequential Organ Failure Assessment Score Simplified Acute Physiology Score Intensive Care Unit Discharge 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE – acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med. 1981;9:591–597.PubMedCrossRefGoogle Scholar
  2. 2.
    Le Gall JR, Loirat P, Alperovitch A. Simplified acute physiological score for intensive care patients. Lancet. 1983;2:741.PubMedCrossRefGoogle Scholar
  3. 3.
    Marshall JC, Cook DA, Christou NV, Bernard GR, Sprung CL, Sibbald WJ. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. 1995;23:1638–1652.PubMedCrossRefGoogle Scholar
  4. 4.
    Le Gall JR, Klar J, Lemeshow S, et al. The logistic organ dysfunction system. A new way to assess organ dysfunction in the intensive care unit. JAMA. 1996;276:802–810.PubMedCrossRefGoogle Scholar
  5. 5.
    Vincent JL, Moreno R, Takala J, et al. The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;22:707–710.PubMedCrossRefGoogle Scholar
  6. 6.
    Moreno R, Reis Miranda D, Matos R, Fevereiro T. Mortality after discharge from intensive care: the impact of organ system failure and nursing workload use at discharge. Intensive Care Med. 2001;27:999–1004.PubMedCrossRefGoogle Scholar
  7. 7.
    Moreno R, Reis Miranda D. Nursing staff in intensive care in Europe. The mismatch between planning and practice. Chest. 1998;113:752–758.PubMedCrossRefGoogle Scholar
  8. 8.
    Cullen DJ, Civetta JM, Briggs BA, Ferrara LC. Therapeutic intervention scoring system: a method for quantitative comparison of patient care. Crit Care Med. 1974;2:57–60.PubMedCrossRefGoogle Scholar
  9. 9.
    Keene AR, Cullen DJ. Therapeutic intervention scoring system: update 1983. Crit Care Med. 1983;11:1–3.PubMedCrossRefGoogle Scholar
  10. 10.
    Reis Miranda D, de Rijk A, Schaufeli W. Simplified Therapeutic Intervention Scoring System: The TISS 28 items – Results from a multicenter study. Crit Care Med. 1996;24:64–73.CrossRefGoogle Scholar
  11. 11.
    Reis Miranda D, Moreno R, Iapichino G. Nine equivalents of nursing manpower use score (NEMS). Intensive Care Med. 1997;23:760–765.PubMedCrossRefGoogle Scholar
  12. 12.
    Reis Miranda D, Nap R, de Rijk A, Schaufeli W, Iapichino G, TISS Working Group. Nursing activities score. Crit Care Med 2003;31:374–382.Google Scholar
  13. 13.
    Apgar V. A proposal for a new method of evaluation of the newborn infant. Anesth Analg. 1953;32:260–267.CrossRefGoogle Scholar
  14. 14.
    Ranson JHC, Rifkind KM, Roses DF, et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974;139:69–81.PubMedGoogle Scholar
  15. 15.
    Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg. 1999;16:9–13.PubMedCrossRefGoogle Scholar
  16. 16.
    Backer S, O’Neill B, Haddon W Jr, Long WN. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187–196.CrossRefGoogle Scholar
  17. 17.
    Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ. Trauma score. Crit Care. 1981;9:672–676.CrossRefGoogle Scholar
  18. 18.
    Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma. 1989;29(5):623–629.PubMedCrossRefGoogle Scholar
  19. 19.
    Champion HR, Sacco WJ, Hunt TK. Trauma severity scoring to predict mortality. World J Surg. 1983;7:4–11.PubMedCrossRefGoogle Scholar
  20. 20.
    Pickering SAW, Esberger D, Moran CG. The outcome following major trauma in the elderly. Predictors of survival. Injury. 1999;30:703–706.PubMedCrossRefGoogle Scholar
  21. 21.
    Sicignano A, Giudici D. Probability model of hospital death for severe trauma patients based on the Simplified Acute Physiology Score I: development and validation. J Trauma. 1997;43:585–589.PubMedCrossRefGoogle Scholar
  22. 22.
    Glance LG, Osler TM, Dick AW. Evaluating trauma center quality: does the choice of the severity-adjustment model make a difference? J Trauma. 2005;58:1265–1271.PubMedCrossRefGoogle Scholar
  23. 23.
    Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–829.PubMedCrossRefGoogle Scholar
  24. 24.
    Knaus WA, Wagner DP, Draper EA, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest. 1991;100:1619–1636.PubMedCrossRefGoogle Scholar
  25. 25.
    Le Gall JR, Lemeshow S, Saulnier F. A new simplified acute physiology score (SAPS II) based on a European / North American multicenter study. JAMA. 1993;270:2957–2963.PubMedCrossRefGoogle Scholar
  26. 26.
    Lemeshow S, Teres D, Klar J, Avrunin JS, Gehlbach SH, Rapoport J. Mortality Probability Models (MPM II) based on an international cohort of intensive care unit patients. JAMA. 1993;270:2478–2486.PubMedCrossRefGoogle Scholar
  27. 27.
    Moreno R, Matos R. The “new” scores: what problems have been fixed, and what remain. Curr Opin Crit Care. 2000;6:158–165.CrossRefGoogle Scholar
  28. 28.
    Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome and associated costs of care. Crit Care Med. 2001;29:1303–1310.PubMedCrossRefGoogle Scholar
  29. 29.
    Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;348:1546–1554.PubMedCrossRefGoogle Scholar
  30. 30.
    Angus DC, Pires Pereira CA, Silva E. Epidemiology of Severe Sepsis Around the World. Endocr Metab Immune Disord Drug Targets. 2006;6:207–212.PubMedCrossRefGoogle Scholar
  31. 31.
    Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001;344:699–709.PubMedCrossRefGoogle Scholar
  32. 32.
    Ely EW, Laterre PF, Angus DC, et al. Drotrecogin alfa (activated) administration across clinically important subgroups of patients with severe sepsis. Crit Care Med. 2003;31:12–19.PubMedCrossRefGoogle Scholar
  33. 33.
    Moreno R, Apolone G. The impact of different customization strategies in the performance of a general severity score. Crit Care Med. 1997;25:2001–2008.PubMedCrossRefGoogle Scholar
  34. 34.
    Zhu BP, Lemeshow S, Hosmer DW, Klarm J, Avrunin J, Teres D. Factors affecting the performance of the models in the mortality probability model and strategies of customization: a simulation study. Crit Care Med. 1996;24:57–63.PubMedCrossRefGoogle Scholar
  35. 35.
    Le Gall JR, Lemeshow S, Leleu G, et al. Customized probability models for early severe sepsis in adult intensive care patients. JAMA. 1995;273:644–650.PubMedCrossRefGoogle Scholar
  36. 36.
    Apolone G, D’Amico R, Bertolini G, et al. The performance of SAPS II in a cohort of patients admitted in 99 Italian ICUs: results from the GiViTI. Intensive Care Med. 1996;22:1368–1378.PubMedCrossRefGoogle Scholar
  37. 37.
    Metnitz PG, Valentin A, Vesely H, et al. Prognostic performance and customization of the SAPS II: results of a multicenter Austrian study. Intensive Care Med. 1999;25:192–197.PubMedCrossRefGoogle Scholar
  38. 38.
    Moreno R, Apolone G, Reis Miranda D. Evaluation of the uniformity of fit of general outcome prediction models. Intensive Care Med. 1998;24:40–47.PubMedCrossRefGoogle Scholar
  39. 39.
    Le Gall JR, Neumann A, Hemery F, et al. Mortality prediction using SAPS II: an update for French intensive care units. Crit Care. 2005;9:R645–R652.PubMedCrossRefGoogle Scholar
  40. 40.
    Aegerter P, Boumendil A, Retbi A, Minvielle E, Dervaux B, Guidet B. SAPS II revisited. Intensive Care Med. 2005;31:416–423.PubMedCrossRefGoogle Scholar
  41. 41.
    Harrison DA, Parry GJ, Carpenter JR, Short A, Rowan K. A new risk prediction model for critical care: The Intensive Care National Audit & Research Centre (ICNARC) model. Crit Care Med. 2007;35:1091–1098.PubMedCrossRefGoogle Scholar
  42. 42.
    Rowan KM, Kerr JH, Major E, McPherson K, Short A, Vessey MP. Intensive Care Society’s APACHE II study in Britain and Ireland – I: variations in case mix of adult admissions to general intensive care units and impact on outcome. Br Med J. 1993;307:972–977.CrossRefGoogle Scholar
  43. 43.
    Rowan KM, Kerr JH, Major E, McPherson K, Short A, Vessey MP. Intensive Care Society’s APACHE II study in Britain and Ireland – II: outcome comparisons of intensive care units after adjustment for case mix by the American APACHE II method. Br Med J. 1993;307:977–981.CrossRefGoogle Scholar
  44. 44.
    Rowan KM, Kerr JH, Major E, McPherson K, Short A, Vessey MP. Intensive Care Society’s Acute Physiology and Chronic Health Evaluation (APACHE II) study in Britain and Ireland: a prospective, multicenter, cohort study comparing two methods for predicting outcome for adult intensive care patients. Crit Care Med. 1994;22:1392–1401.PubMedCrossRefGoogle Scholar
  45. 45.
    Higgins TL, Teres D, Copes WS, Nathanson BH, Stark M, Kramer AA. Assessing contemporary intensive care unit outcome: an updated Mortality Probability Admission Model (MPM0-III). Crit Care Med. 2007;35:827–835.PubMedCrossRefGoogle Scholar
  46. 46.
    Metnitz PG, Moreno RP, Almeida E, et al. SAPS 3. From evaluation of the patient to evaluation of the intensive care unit. Part 1: objectives, methods and cohort description. Intensive Care Med. 2005;31:1336–1344.PubMedCrossRefGoogle Scholar
  47. 47.
    Moreno RP, Metnitz PG, Almeida E, et al. SAPS 3. From evaluation of the patient to evaluation of the intensive care unit. Part 2: development of a prognostic model for hospital mortality at ICU admission. Intensive Care Med. 2005;31:1345–1355.PubMedCrossRefGoogle Scholar
  48. 48.
    Zimmerman JE, Kramer AA, McNair DS, Malila FM. Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today’s critically ill patients. Crit Care Med. 2006;34:1297–1310.PubMedCrossRefGoogle Scholar
  49. 49.
    Bertleff MJ, Bruining HA. How should multiple organ dysfunction syndrome be assessed? A review of the variations in current scoring systems. Eur J Surg. 1997;163:405–409.PubMedGoogle Scholar
  50. 50.
    Marshall JD, Bernard G, Le Gall JR, Vincent J-L. The measurement of organ dysfunction/failure as an ICU outcome. Sepsis. 1997;1:41.CrossRefGoogle Scholar
  51. 51.
    Elebute EA, Stoner HB. The grading of sepsis. Br J Surg. 1983;70:29–31.PubMedCrossRefGoogle Scholar
  52. 52.
    Stevens LE. Gauging the severity of surgical sepsis. Arch Surg. 1983;118:1190–1192.PubMedCrossRefGoogle Scholar
  53. 53.
    Meek M, Munster AM, Winchurch RA, et al. The Baltimore Sepsis Scale: measurement of sepsis in patients with burns using a new scoring system. J Burn Care Rehabil. 1991;12:564–568.PubMedCrossRefGoogle Scholar
  54. 54.
    Baumgartner JD, Bula C, Vaney C, et al. A novel score for predicting the mortality of septic shock patients. Crit Care Med. 1992;20:953–960.PubMedCrossRefGoogle Scholar
  55. 55.
    Moreno R, Pereira E, Matos R, Fevereiro T. The evaluation of cardiovascular dysfunction/failure in multiple organ failure [abstract]. Intensive Care Med. 1997;23:S153.Google Scholar
  56. 56.
    Moreno R, Vincent JL, Matos R, et al. The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care. Results of a prospective, multicentre study. Intensive Care Med. 1999;25:686–696.PubMedCrossRefGoogle Scholar
  57. 57.
    Chang RW, Jacobs S, Lee B. Predicting outcome among intensive care unit patients using computerised trend analysis of daily Apache II scores corrected for organ system failure. Intensive Care Med. 1988;14:558–566.PubMedCrossRefGoogle Scholar
  58. 58.
    Timsit JF, Fosse JP, Troche G, et al. Accuracy of a composite score using daily SAPS II and LOD scores for predicting hospital mortality in ICU patients hospitalized for more than 72 h. Intensive Care Med. 2001;27:1012–1021.PubMedCrossRefGoogle Scholar
  59. 59.
    Villar J, Flores C, Méndez-Alvarez S. Genetic susceptibility to acute lung injury. Crit Care Med. 2003;31:S272–S275.PubMedCrossRefGoogle Scholar
  60. 60.
    Villar J, Maca-Meyer N, Pérez-Méndez L, Flores C. Understanding genetic predisposition to sepsis. Crit Care. 2004;8:180–189.PubMedCrossRefGoogle Scholar
  61. 61.
    Sinuff T, Adhikari NKJ, Cook DJ, et al. Mortality predictions in the intensive care unit: comparing physicians with scoring systems. Crit Care Med. 2006;34:878–885.PubMedCrossRefGoogle Scholar
  62. 62.
    Booth FV, Short M, Shorr AF, et al. Application of a population-based severity scoring system to individual patients results in frequent misclassification. Crit Care. 2006;9:R522–R529.CrossRefGoogle Scholar
  63. 63.
    Rowan K. The reliability of case mix measurements in intensive care. Curr Opin Crit Care. 1996;2:209–213.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Rui Moreno
    • 1
  • Isabel Miranda
    • 2
  1. 1.Intensive Care Unit, Centro Hospitalar de Lisboa CentralE.P.E., Hospital de St. António dos CapuchosLisboaPortugal
  2. 2.Intensive Care Unit, Centro Hospitalar de Lisboa CentralE.P.E. Hospital de St. António dos CapuchosLisboaPortugal

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